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Journal of Advanced Research (2012) 3, 109–117

Cairo University

Journal of Advanced Research

ORIGINAL ARTICLE

Polarity effect of microcurrent electrical stimulation on tendon healing: Biomechanical and histopathological studies
Amal F. Ahmed
a b c

a,*

, Sherein S.A. Elgayed b, Ibrahim M. Ibrahim

c

Basic Sciences Department, Faculty of Physical Therapy, Cairo University, Giza, Egypt Pathology Department, Faculty of Veterinary Medicine, Cairo University, Giza, Egypt Department of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, Cairo University, Giza, Egypt

Received 12 November 2010; revised 3 May 2011; accepted 8 May 2011 Available online 11 June 2011

KEYWORDS Microcurrent electrical stimulation; Tendon; Healing; Polarity; Biomechanical testing

Abstract The purpose of the current study was to investigate the effect of microcurrent electrical stimulation (MES) applied with different polarity on the biomechanical properties of injured tendons and to correlate results with histopathological studies. Ninety six male white New Zealand rabbits were used in the study. Six rabbits were kept as normal group with intact tendons and the remaining 90 rabbits with their right Achilles tendons tenotomized, sutured and immobilized. After that rabbits were allocated into equal three groups; cathodal, anodal and control. Each group was further subdivided into three subgroups according to the study period; 3, 5 and 8 weeks. There were significant increases of all biomechanical measurements for cathodal and anodal groups than those of control group at all study periods. Furthermore there were significant increases of all biomechanical measurements in the cathodal group more than the anodal group at the 3 week period, while there was significant increase of the anodal group more than the cathodal at 5 and 8 week periods. The histopathological findings supported the biomechanical results. Tendons in cathode group showed better healing picture compared to those of anodal group at third week. While tendons in the anodal group showed better improvement at the 5 and 8 week. MES improved the healing

* Corresponding author. Tel.: +20 123819707; fax: +20 237617692. E-mail address: amoshfoz88@yahoo.com (A.F. Ahmed). 2090-1232 ª 2011 Cairo University. Production and hosting by Elsevier B.V. All rights reserved. Peer review under responsibility of Cairo University. doi:10.1016/j.jare.2011.05.004

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Production and hosting by Elsevier B. Introduction Injury of the dense connective tissues as tendons and ligaments. 7 of the tendons were used for biomechanical measurements and 3 were processed for histopathological studies. 4–6 months .11–15]. more comparative studies are needed to compare and standardize the ideal polarity at each stage of tendon healing. To standardize the injury mode in both groups. So. After that. 5 and 8 weeks (n = 10 in each). a complete surgical transection of the Achilles tendon was performed. Therefore. rabbits were randomly divided into equal three groups (n = 30 in each) by a technician not involved in the surgery. In each subgroup. Barcelona. USA) using modified Kessler suture technique. It was suggested that a means of enhancing intrinsic repair mechanisms would be highly desirable [3–6]. Germany). food was withheld 12 h while water was withheld 3 h before the operation. Afterward. An important parameter of electrical stimulation in healing is the type of applied polarity which may affect protein synthesis. Cairo University.5 kg. It was reported that MES plays a significant role in enhancing the healing process of tissue healing [9]. cell migration. the operated limb was immobilized using Plaster of Paris cast with the knee in flexion Material and methods Animal model The ethical committee of the Faculty of Physical Therapy. and subjected to comprehensive veterinary care. it has the privilege of using electric currents similar to those produced by the body during tissue healing and it may be a particularly beneficial where endogenous healing has failed [7. humidity (50%) and light (a 12 h light/dark cycle). ª 2011 Cairo University.8]. about 1 cm apart from calcaneal insertion. The proposed mechanisms by which MES produced its effect are. Immediately before the surgery the hair was removed from the site of the operation.12]. Surgical procedures In preparation for surgery. In particular.15]. were used in this study. Tendons are characterized by their slow rate of healing and much debate has been aroused concerning the intrinsic capacity of tendons to heal after injury. edema. old male New Zealand White rabbits. All surgical techniques were done under sterile conditions according to the following steps (Fig.12. either compromises the future performance of the individual or predisposes to an increase risk of recurrent injury [1.V.2]. Each rabbit was weighed before the operation for the determination of the dose of anesthesia. MES is a low-intensity current that delivers monophasic or biphasic pulsed microamperage currents usually between 1 microampere (lA) and 1000 lA.8. The remaining hair was short cut using hair scissor. Some studies have reported significant improvement of tendon healing using negative polarity [11.) The rabbits were kept at the same conditions of temperature (about 20 °C).14]. Leverkusen. The animals were housed individually in a standard rabbit cage of 15 · 20 · 20 cm. process of tendon and the polarity of MES could be an important factor to be considered in treating tendon injuries. electrotaxis. promoting amino acid uptake. The resolution of such injuries often fails to restore the normal morphologic and functional characteristics of the tissue structure and therefore. Intrinsic healing results in improved biomechanics and has less complication.F. Ninety six. but they could move around freely. and also the processes of bioelectric events of injury [10. The right Achilles tendon was exposed and dissected using a longitudinal incision of about 3 cm in length on the medial aspect of the leg extending from just above the heel to the middle of the leg. growth of bacteria. 1). (The size of the cages did not allow them full activity such as running. many studies have been conducted using variable current parameters. and enhancing protein synthesis in human fibroblasts [4. The rabbits were anesthetized by general anesthesia using combination of intramuscular injection of ketamine hydrochloride (35 mg/kg body weight) (Ketalar (Parke–Davis SA. the present study investigated the effect of MES with different polarity on the biomechanical and histopathological properties of surgically repaired rabbits Achilles tendon at different stages of healing. Tendons have shown a capacity for healing.110 A. The animal was immobilized on the surgical table in a side lying position. Tendons in the cathodal and anodal groups were treated with MES while those of the control group did not receive MES treatment. MES is thought to mirror the body’s own natural current as so. NY.10]. Faculty of Agriculture. After that both ends of the severed Achilles tendon were approximated and sutured by 4/0 Proline (Ethicon. The remaining ninety rabbits.16–19]. a normal gliding mechanism within the tendon sheath is preserved. at the posterior and medial aspects of the hind limb using hair removal cream. either from acute trauma or repetitive strain lesions results in protracted periods of disability. inflammation. All rights reserved. either alone or in conjunction with extratendinous structures. The rabbits were assigned to normal group served as a basic reference and three studied groups. despite the presence of many studies on the effect of MES on tendon healing. their right Achilles tendons were tenotomized. Tap water and balanced diet were given ad libitum throughout the study. Ahmed et al. The normal group included six rabbits with intact tendons five of which were used for biomechanical measurements and one was processed for histopathological studies. Spain) and Xylazin hydrochloride (5 mg/kg body weight) (Rompun 2% (Bayer. current density and polarity [11. with average weight 2– 2. anodal and control and each group was further subdivided into three subgroups according to the study period. The rabbits were purchased from the Rabbit Production Unit. sutured and immobilized. Achilles tendon was sharply transected with a scalpel. while others reported significant improvement using positive polarity [13. Regarding the effect of MES on tendon healing. and demonstrated that MES improves tendon healing [4. 3. The skin was then closed by interrupted silk sutures. increasing adenosine triphosphate (ATP) concentration. Cairo University approved this study. The studied groups were cathodal. The effect of MES may be related to the selected treatment parameters as current intensity.

sections were cut and fixed in 10% neutral buffer formalin for routine processing. those tendons were preserved in saline 9% concentration and freezed at À70 °C until biomechanical tests were performed [21]. Japan) was used to deliver MES. approximately 3 cm apart. Cairo. each rabbit was positioned relaxed on his side and two disposable electrodes (ECG electrodes Ag/Ag Cl (Leonhard Lang Gmbh. As shown in Fig. After removal. tendons were exposed under general anesthesia as previously described. For tendons used for biomechanical measurements.. Korea). pulse width 50 ms. (C) repair and (D) skin closure and immobilization with window at tenotomy site. intensity 100 lA/cm2. Tendons harvesting According to the assigned time of each group. National Research Center.14]. 1 (A) The right Achilles tendon after dissection. Austria). For tendons used for histopathological studies. (B) tenotomy. 2 Application of MES using active electrode at the tenotomy site and ground electrode proximally placed. Before treatment the skin was cleaned and any growing hair was removed to decrease the electrical resistance of the skin over the site of the electrode placement. On the sixth postoperative day. 2 during treatment. The active electrode (1. while the inactive electrode was placed proximally on the thigh region of the same side. Biomechanical measurements The Biomechanical analysis was made at the Cellulose and Paper Department. Sharp transverse cuts were made part of the calcaneal bone below and fleshy muscles above were incised to give stability and prevent slack of the tendon during measurements.13. The device was calibrated using EZ Digital 60 MHz Analog Oscilloscope OS5060A (EZ Digital Co. All rabbits were returned back to their cages and were fed ad libitum with prophylactic antibiotic to their drinking water. were used. Tokyo. The following parameters were used. the cast was removed and the animals were weighted. Microcurrent electrical stimulation application Rabbits in both anodal and cathodal groups were treated transcutaneously at the tenotomy site using MES according to a treatment regimen of 6 sessions/week on a daily basis from the first day post surgery and for the entire duration of the study (3. with a duration 30 min [8. and ankle held in 45° of plantar flexion so that the calf muscle was in a shortened position [20]. pulse frequency 10 Hz. . 5 and 8 weeks). Ltd.0 cm) was placed over the tendon injury site. The tendons were freed carefully from the surrounding and the sutures were carefully removed before tendon excision. A Trio 300 electric stimulator (ITO. A window was done at the site of the tenotomy for wound dressing and MES application.Effect of microcurrent electrical stimulation on tendon healing 111 Fig. Gyeonggi. Dokki.0 · 1. The polarity of the active electrode was positive for anodal group and negative for the cathodal group. all cast were removed and unlimited movements of the rabbits within cages were permitted. Innsbruck. The excised tendons were assigned for biomechanical or histopathological studies. The right Achilles Fig.

standard deviation (SD) and the percentages of these measures in relation to that of the normal intact Achilles tendons. The specimen was kept moist throughout testing using normal saline to avoid tensile strength changes associated with drying.000). mJ: milli Joule . Factorial ANOVA was used to determine the effect of time and MES and a Post –hoc test (LSD) was then used to determine differences between weeks 3.72 Stiffness (N/mm) 124.000) (Table 3). Effect of MES: As shown in Table 4. Tokyo. 5. West Sussex.68 Elastic modulus (N/mm2) 54. the study included five dependent variables which were the measured biomechanical parameters and two independent variables which were time and MES. The blocks were cut at 6 lm thickness and the sections were stained with (Hematoxyline and Eosin H&E) for histological examination [23].65 SD = standard deviation. 0. 8 were significantly higher than the control group (P = 0. 8 weeks) within each groups (P = 0.02) while at weeks 5 and 8 that of the anodal group were significantly higher than cathodal group (P = 0. including: load at break in Newton (N) (amount of load applied beyond which the tendon will fail). Toagosei Co Ltd. Results Biomechanical results The results of all biomechanical parameters of the tenotomized and repaired tendons in the three experimental groups were Table 1 Mean SD A. and at week 5 load at break was also significantly higher than week 3 (P = 0. Japan). cathodal and anodal groups respectively) (Table 3). 8 were significantly higher than the control group (P = 0.00 74. N/mm: Newton/millimeter. 5. and at week 5 also was significantly higher than week 3 (P = 0.000). Each tendon was loaded to failure (till tendon rupture) at a constant crosshead speed of 50 mm/min.006 and 0. found to be lower compared to those of the normal intact tendons with the highest percent of improvement recorded from the three studied groups at week 8 for all the biomechanical measures (Tables 1 and 2). 5. Elastic modulus Effect of time: Elastic modulus of the three groups at week 8 was significantly higher than those of weeks 3 and 5 Biomechanical values of normal group. elastic modulus in Newton/millimeter2 (N/mm2) (the slope of the stress strain curve in the elastic deformation region) and work done in milli Joule (mJ) (the amount of energy transferred by a force acting through a distance) [22].112 Egypt.000) and that of the cathodal group was significantly higher than that of the anodal group at weeks 3 (P = 0.000) (Table 3). load at break values of the cathodal and anodal groups at weeks 3. N: Newton.F. jaws secured the calcaneus at one end and the musculotendinous junction at the other. stiffness values of the cathodal and anodal groups at weeks 3. dehydrated in alcohol.000). cleaned in Xylol and embedded in paraffin.64 Work done (mJ) 2093.003. A load deformation curve and other biomechanical parameters were obtained. Significance level was set at (0.000 respectively). UTS of the cathodal and anodal groups at weeks 3.001 respectively). load at break at week 8 was significantly higher than those of weeks 3 and 5 (P = 0.001. Ahmed et al. In the three studied groups. UTS: ultimate tensile strength.04) while at weeks 5 and 8 that of the anodal group were significantly higher than cathodal group (P = 0.95 5.78 UTS (N) 301. The biomechanical results were presented in the form of mean. stiffness in Newton/ millimeter (N/mm) (resistance to deformation). ultimate tensile strength in Newton (N) (maximum stress that tendon can withstand while being pulled before necking). 8 and the differences between control. 5. 8 was significantly higher than the control group (P = 0. UTS at week 8 was significantly higher than those of weeks 3 and 5 (P = 0. The tensile machine Lloyd instruments LR10K (Lloyd Instruments Ltd.84 4.21 15. Load at break Effect of time: Load at break differ significantly throughout the study periods (3.000) and that of the cathodal group was significantly higher than that of the anodal group at weeks 3 (P = 0. Ultimate tensile strength (UTS) Effect of time: Regarding changes across study period. The musculotendinous junction end of the Achilles tendon was fixed between two pieces of sandpaper and was mounted and secured with quick-setting superglue (Aron Alpha. UK) was used to measure biomechanical properties of the tendons. Stiffness Effect of time: Regarding changes across study period.000) and that of the cathodal group was significantly higher than that of the anodal group at weeks 3 (P = 0. Effect of MES: As shown in Table 4. Stiffness at week 8 was significantly higher than those of weeks 3 and 5 (P = 0. cathodal and anodal groups. Each tendon was clamped at each end of serrated grips. Load at break (N) 215. Histopathological study Specimens were fixed in 10% neutral buffered formalin for one week. and at week 5 also was significantly higher than week 3 (P = 0. According to the experimental design. 5. Effect of MES: As shown in Table 4.000). and 0.0.66 9.000).01. and 0. Statistical analysis Statistical analysis was performed using ‘‘SPSS’’ for windows evaluation version 15.05).04) and anodal group was significantly higher than cathodal group at weeks 5 and 8 (P = 0. The system was loaded to 250 N load cells.004 for control.

Third week Control Load at break (N) Mean 56.1 38.000* 0.9 2.000* 0.14 4.06 40% 159. and at week 5 also was significantly higher than week 3 (P = 0.01 2. cathodal and anodal groups respectively (Table 3).87 52.61 5.000). SE 2.000* 0.17 28.000* 0.53 10.5 52.23 53.2% 1270 49.07 52.96 Elastic modulus (N/mm2) Week 3 vs week 5 6.000* 0.7% 17.93 6.71 Week 5 vs week 8 8.57 33.63 25.29 4.67 45.72 44.18 SD 5.7% 1103.36 31. Control group Mean Diff.45 41. 8 were significantly higher than the control group (P = 0.27 5.000* 0. N/mm: Newton/millimeter. * Significant difference. 0.86 1.000* 0.00 SD 1.005 Sig.93 6.28 4.2% Anodal 103.2 1.2 52.38 52. N: Newton.000* 0.4 1.72 40% Anodal 78.09 7. %: percentage to corresponding normal.000* 0.14 50% 26.28 26.09 31% 35.19 8.2 1.29 2.37 6.005 6.86 28% 122.71 SE 2.01 12.5 85.39 76.7% 511.9 1.2 1.44 SD 1.14 5. J: Joule.9 2.23 40.25 68.5% Work done (mJ) Mean 450 SD 54.93 1.13 48.000* 0. the values of the elastic modulus of the cathodal and anodal groups at weeks 3.52 31.9 2.57 SE 2.005 6.29 4.71 208.89 36.09 107.000* 0.000* 0.2 3.4 3.75 2.71 2. mJ: milli Joule Table 3 Comparison of the biomechanical measurements across study time within the study groups.1% Control 66.16 4.9 1.000* 0.7 81.005 6.005 6.4% 757.16 47.98 59.97 4.000* 0.98 1.91 % 14.000* 0.12 26.86 34.9 1.4 1.241 64% 206.2 3.84 44% 53.6% 948.000* 0.78 32.44 39% 35.5% SD: standard deviation.37 10.000* 0.7% Control 86.002.000 for control.6% Elastic modulus (N/mm2) Mean 8. (P = 0.000) .000* 0.93 47% 22.26 3.5% 113 Anodal 141.4% Eighth week Cathodal 131.00 66.55 13.3 9.000* 0.05 40% 58.76 23% Cathodal 84.74 30% 12.54 41% 14.01.25 36% 32.2 3.000* 0.93 1.08 61% 80.91 1. UTS: ultimate tensile strength.86 115 266. 11.000* 0.4 1. Effect of MES: As shown in Table 4.47 36.42 86.71 3.15 20.000* 0.2 3.71 147 Mean diff: mean difference.86 23.57 345.4 3.00 24.4% 658.005 6.000* 0.2 3.22 73% 47.38 67% 85.93 6.000* 0. N: Newton.86 19.57 151.44 7.000* 0.43 20.28 63.000* 0.9 2.Effect of microcurrent electrical stimulation on tendon healing Table 2 Biomechanical measurements of the studied groups through the study period.63 2.33 5.005 Sig.80 68% 218.57 Work Week Week Week done (J) 3 vs week 5 3 vs week 8 5 vs week 8 61. SE: standard error of the mean difference.7% 98.000* Anodal group Mean Diff.005 Sig.93 1. 5.2 3.000* 0.8 23.14 Week 3 vs week 8 14.4 1.43 166.002* 0.000* Cathodal group Mean Diff.81 43% 141.9 8. N/mm: Newton/millimeter. 0.76 65.4% Fifth week Cathodal 95.1 7.000* 0.00 56.21 5.37 68% 42.8% 1099.000* 0.77 20.000* 0.93 90.000* 0.25 36.05 2.000* 0.38 60.24 6.93 1.40 42.19 47% 150.91 % 21.9 2.000* Treatment time Load at break (N) Week 3 vs week 5 Week 3 vs week 8 Week 5 vs week 8 Stiffness (N/mm) Week 3 vs week 5 Week 3 vs week 8 Week 5 vs week 8 UTS (N) Week 3 vs week 5 Week 3 vs week 8 Week 5 vs week 8 10.000* 0. 24.000* 0.93 1.14 30.005 6.000* 0. 0.03 4.4 1.32 5.93 1.4 3.71 512.4 1. 0.000* 0.70 61.000* 0.5% 833.60 53% 22.40 127.31 26% 90.64 24.01* 0.09 17.02 48% 59. UTS: ultimate tensile strength. and 0.37 % 18% UTS (N) Mean SD % 68.000* 0.22 % 26% Stiffness (N/mm) Mean 22.9 2.000* 0.000* 0.

93 1.114 and that of the cathodal group was significantly higher than that of the anodal group at weeks 3 (P = 0. À7.005 6.000* 0.93 1.93 1.000* 0.000* 0.93 1.04 À5.4 1.2 1.000) (Table 4).01* 0.51 À12.9 2. Sig. .005 6. Inflammatory tissue reaction with notice of the newly formed blood vessels and few numbers of inflammatory cells. Tendons in the anodal group showed lessorganized fibroploriferative changes with poorly aligned collagen bundles.000* 0. While that of the cathodal group.09 2. 4C). 3).000* 0.18 À4.64 30.000* 0.20 55.04* 0.000* 0.93 6.29 591.2 3. Inflammatory tissue reaction with mononuclear cells (macrophage) infiltrations is clearly noticed.000* 0.86 611.84 45.93 6.000* 0.4 1. UTS: ultimate tensile strength.000). 3 Normal tendon consisting of mature compact bundles entangling compressed few fibrocytes (H&E 400·).79 27. À9.9 2.93 1. 5. 4A).29 436.9 1. Week 5: Histological changes of the control tendons showed high cellularity in relation to the fibrils.93 1.35 22.43 440.2 1. Work done by the tendons in the three groups at week 8 was significantly higher than those of weeks 3 and 5 (P = 0.10 22.000* 0.57 À170.14 19. Histopathological results The normal rabbit Achilles tendon consisted of closely packed bundles of collagen fibers with relatively few fibrocytes which were aligned with the collagen fibers along the longitudinal axis of the tendon (Fig.005 Sig. Table 4 Comparison between studied groups at different treatment time.000* 0.000* 0.71 4. Effect of MES: The work done by tendons of the cathodal and anodal groups at weeks 3.02 and 0. N: Newton.97 28. * Significant difference.000* 0.000* 0.000* 0.04 À9.000).4 1.29 4.000* 0. (Fig.4 3.000* 0.005 Sig.02* 0. Week 3: Regarding the control non treated tenotomized and repaired tendons.55 47. 0. significance level. 8 were significantly higher than the control group (P = 0.4 1.01* 0.000* 0. J: Joule.77 À5.2 3.93 13.2 1.4 1.005 Sig.2 3. revealed well developed granulation tissue with a properly aligned pattern of collagen A.9 1.56 29.14 12.000* 0.42 18.000* 0.000* 0.001* 0. Many attempts to form bundles with parallel fibers were observed but still Fig.12 36. N/mm: Newton/millimeter.43 8.4 1.005 6.77 À5.9 2. Ahmed et al.57 Fifth week SE 2. SE 2.43 9.22 59.43 383 307.000* 0.62 24.02* 0.000) and that of the cathodal group was significantly higher than that of the anodal group at weeks 3 (P = 0.000* 0.000* Compared groups Load at break (N) Cathodal vs anodal Cathodal vs control Anodal vs control Stiffness (N/mm) Cathodal vs anodal Cathodal vs control Anodal vs control UTS (N) Cathodal vs anodal Cathodal vs control Anodal vs control Elastic modulus (N/mm2) Cathodal vs anodal Cathodal vs control Anodal vs control Work done (J) Cathodal vs anodal Cathodal vs control Anodal vs control 6.005 6. the microscopic findings revealed less organized fibroploriferative changes with poorly aligned collagen bundles.000* 0.47 10.4 3.F. bundles (Fig.04* 0.54 7.9 2.02) while at weeks 5 and 8 that of the anodal group were significantly higher than cathodal group (P = 0.43 24. and at week 5 was significantly higher than week 3 (P = 0.9 2.000* 0.2 3.006* 0.2 3.005 6. 0.000* 0.005 6. Third week Mean Diff. (Fig.000* 0.86 75.93 6.000* 0.9 1.4 3. Work done Effect of time: As presented in Table 3.2 3.21 18.000* 0.000* 0.01 respectively). 0.000* 0.000* Eighth week Mean Diff.57 Mean diff: mean difference.72 21.02* 0.000* Mean Diff.57 À155.02* 0.01 28.000* 0.9 2. SE: standard error of the mean difference.000) while at weeks 5 and 8 that of the anodal group was significantly higher than cathodal group (P = 0.29 SE 2. 4B).

(A) Untreated control showing less-organized fibroploriferative changes with poorly aligned collagen bands. Both of them are well oriented along the longitudinal axis of the tendon. (B) Photomicrograph of cathodal group showing well-developed granulation tissue with a properly aligned pattern of collagen bands. (B) Photomicrograph of cathodal MES stimulation showing diminished granulation tissue with formation of properly aligned mature collagen bundles. (A) Photomicrograph of untreated tenotomized left Achilles tendon showing poorly aligned collagen bundles. Inflammatory tissue reaction is observed. (C) Anodal MES showing mature collagen fibers with fibrocystes in-between. (C) Photomicrograph of anodal treated tendons showing well-organized fibroploriferative changes. Fig. inflammatory tissue reaction with mononuclear cells infiltrations is clearly noticed. 6 Photomicrograph of an eight week neotendon (H&E 200·). Inflammatory tissue reaction with notice of the newly formed blood vessels and few numbers of inflammatory cells. . 5 Photomicrograph of a five weeks neotendon (H&E 200·). Notice foreign body granulomatous reaction. (B) Photomicrograph of cathodal MES showing cellular neotendon.Effect of microcurrent electrical stimulation on tendon healing 115 Fig. Notice attempts to form bundles with parallel fibers but still in disarray. small blood vessels and collagen fibers appears scattered and in loose bundles. 4 Photomicrograph of a three week neotendon (H&E 200·). (A) Untreated neotendon showing high cellularity in relation to the fibers. (C) Photomicrograph of Anodal MES stimulation showing closely packed collagen bundles with compressed fibrocytes. Fig.

Employing different levels of current. One limitation to this study was that. while others reported positive results with anodal MES [13. they facilitate angiogenesis. only one study was conducted by Owoeye et al. although fibroblasts are dominant and produce the collagen of tendons. This might explain the significant improvement of both biomechanical properties and healing picture of the healed tendons treated with anodal MES in the anodal group. MES mimic endogenous electrical signal that guide cellular behavior which results in stimulating intrinsic capacity of tendon to heal with minimal complications [4. The biomechanical properties of tendons were reported to be directly related to the amount and orderly orientation of collagen fibers which are responsible for transmitting the force generated by the tendon to bone [24]. While tendons in the anodal group. 6C). 5A). Early cast removing and functional loading were reported to augment the healing strength of the experimentally tenotomized Achilles tendons and to reduce the complications of prolonged immobilization [20. while anodal MES showed more significant improvements in the 5 and 8 weeks.18]. [14] were comparing the cathodal and nodal MES on tendon healing.11] Furthermore the results of the current study shed a light on the role of polarity of MES as a parameter during stimulation of tendon healing throughout the different healing periods.7]. the authors used implanted electrode with stainless which might have affected the outcome also they used pulsed galvanic current in the form of twin spike not in the form of rectangular which may be a factor to be considered. Cathodal stimulation was suggested to promote and attract macrophages [26]. So we can suggest that with MES application to the surgically repaired tendons. According to the biomechanical and histopathological findings.25]. greater tensile strength and load at break means increased ability to perform movement. The findings in our study regarding anodal MES agree with them but contradict their result regarding cathodal MES. Regarding the Cathodal group. According to the experimental design of the study. the right Achilles tendon showed diminished granulation tissue with formation of properly aligned mature collagen bundles (Fig. it was sug- . Regarding the cathodal group. 6A). showed closely packed collagen bundles with compressed fibrocytes. and their proliferation prior to collagen synthesis.14].17–19]. Furthermore. enhancing active secretion of tenocytes and increasing collagen synthesis [4. While higher stiffness.116 disarray (Fig. migration of fibroblasts to the site of injury. This was also proved by the presented histopathological findings as tendons in the cathodal and anodal groups showed less prominent inflammatory reactions with better aligned collagen fibers which were organized in parallel bundles. tendons and ligaments and promising results have been reported [9.13. Not only do macrophages debride the injury site via phagocytosis. increasing amino acid uptake. Thus. 6B). Obvious foreign body granulomatous reaction could be seen (Fig.F. Recently MES has gained considerable attention for stimulating soft tissues repair as wounds.28] The intensity and pulse frequency of MES used in the study were chosen according to previous studies which suggested the optimal range for the best biological effect of microcurrent therapy [8. Most of the studies conducted on the effect of MES on tendon healing used single polarity Some reported that cathodal MES could enhance tendon healing [11. showed the best healing picture with spindle shaped fibrocytes arranged parallel to the longitudinal axis of the collagen fibers which form compact bundles (Fig. anodal stimulation was suggested to facilitate migration and proliferation of epithelial cells so improving wound closure [10. The improvement in both the biomechanical properties and healing process recorded in both MES groups could be explained by the previously reported physiological effects of MES that related to enhancement of the intrinsic healing of the tendon include promoting ATP production. the results demonstrated that both cathodal and anodal MES could improve the mechanical properties of surgically repaired rabbits Achilles tendons at third. In this study. Week 8: Light microscopy of untreated tenotomized right Achilles tendon showed poorly aligned collagen bundles. Ahmed et al. In this study. inflammatory tissue reaction could be noticed (Fig.9.24]. 5B). It was reported that the regenerating Achilles tendon undergoes different stages of healing and each stage involves a different set of cellular events [23]. The previous explanation may explain the significant higher values of cathodal than anodal during the 3 week period. macrophages play a prominent role in healing. A. frequency and polarity have been shown to have diverse effects upon different cell groups [9. we induced complete surgical transection of the Achilles Discussion and conclusion The ultimate aim in treatment of tendon injury is to achieve anatomical and functional healing [22]. their metabolic process may be remarkably impaired in the absence of macrophages that initiate the sequence of events that precede their migration [27]. During the first stage. The Anodal group. MES with positive polarity was suggested to accelerate the process of tendon repair resulting in stronger tendons with reduced contracture formation [13]. The biomechanical testing of the regenerating tendons is considered as one of the criteria to judge the degree of tendon healing.8. bones. On the other hand. fifth and eighth weeks post-injury when compared with the controls. It was suggested that the waveform to be rectangular that resemble body activity [8]. cathodal MES showed significant improvements than anodal MES in the 3-week. Regarding tendon healing.14]. for standardization. 5C). However. safe early mobilization could be allowed. authors found no significant effect for the cathodal than control. tendons showed better healing picture than control group with cellular neotendon. Both of them are well oriented along the longitudinal axis of the tendon (Fig. the plaster casts were removed at sixth day postoperative which allowed early mobilization without any tendon rupture or recorded drawback of the results. elastic modulus and work done means increase of the ability to withstand load for a longer period of time before sniping [20. Up to our knowledge. newly formed small blood vessels and collagen fibers that appeared in loose bundles.12]. gested that microcurrent applications are believed to be effective by influencing and modifying cellular processes and activity.10. It was also reported that tendons treated with anodal MES had higher breaking strength than control which means that tendons became stronger and can withstand higher loads before breaking [14].

So this issue could be studied in future research. [8] Cheng N.90(1):85–109. Van Hoof H. Tateishi T. Effects of micro-amperage direct current stimulation on injury potential and its relation to wound surface area in guinea pig. Low-volt pulsed microamp stimulation: Part 1. Connective tissue plasticity: ultrastructural. [7] Picker RI. Mulier JC. for improving the healing of surgically repaired rabbits tendons. Angoules AG. [12] Akai M. [26] Lampe KE. Watson T.33(1):102–12. The use of electricity in ligament and tendon repair. [2] Enwemeka CS. Rubinovich M. Eplasty 2008. Clin Orthop Relat Res 1982(171):264–72. Tendon: Biology. Maroufi M. J Hand Ther 1998. [25] Becker RO. it may be germane to adjust the MES polarity differently for the different stages of healing to obtain optimal effects. Fung DTC. Effects of low-voltage microamperage stimulation on tendon healing in rats. J Orthop Sports Phys Ther 1991. Hoogmartens MJ. 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